As Health Care Costs Take a Toll, Some Changes Win Broad Backing

Costs in the nation's health care system are ensnaring millions more Americans: One in four report problems paying their medical bills, and nearly three in 10 -- rising to nearly half of women with children -- have put off treatment because of the cost, often despite a serious illness or condition. Both are new highs in polls dating back a decade or more.

Such problems contribute to substantial public disapproval of the country's health care system overall, in terms of its cost, the level of uninsured Americans, and to a lesser extent, the quality of care. Yet most people remain satisfied with their own personal costs, coverage and care --experience that makes the risk of change less attractive.

Still, support for change does exist. Most Americans, 56 percent, favor shifting from the current health system to a taxpayer-financed universal health insurance program. But there are provisos: Support has slipped a bit from its 2003 level, as Republicans have moved farther away from the idea. And support for universal coverage drops sharply if it means higher costs, waiting lists for some care or less choice of doctors or treatments.

Support goes much higher for other, somewhat less fundamental, changes. Large majorities favor employer mandates, expanded government health insurance programs and special aid to provide low-income Americans with health coverage. Many of these are not only supported by much of the public, but "strongly" so.

This extensive survey on public attitudes on health care was conducted by ABC News; the Henry J. Kaiser Family Foundation, an independent non-profit research organization that specializes in health care issues; and USA Today. The poll supports a weeklong series, "Prescription for Change: Fixing American Health Care," Oct. 15-20 on ABC.

The poll finds that one reason for discontent with the current system is apprehension about the future. A minority of Americans, 40 percent, are dissatisfied with their own current health care costs. But, given rising rates, six in 10 insured people are worried about being able to afford their premiums over the next few years. And nearly as many worry they could lose their insurance because of the loss of a job. (Many fewer, though, are very worried.)

Cost and insecurity aren't the only concerns: Despite generally positive personal experiences, more than half, 54 percent, are dissatisfied with the quality of health care generally in the country. And 89 percent call the number of uninsured Americans a serious problem or worse, including 52 percent who call it "critical."

Proposals -- Given concerns about losing insurance through the loss of a job, an employer mandate is among the most popular possible changes to the current system. Nearly eight in 10 favor a federal requirement that all employers offer insurance to their full-time workers; 69 percent "strongly" support it.

Nearly two-thirds favor such a requirement for part-time employees as well. And to help pay for it, a vast 86 percent favor tax breaks or other incentives to businesses that do offer health insurance to their workers. Six in 10 strongly back that idea.

Such a mandate would have an impact: In this survey, nine percent of Americans who hold full-time jobs report that they currently have no health insurance, and it's 14 percent among those who are employed part-time. (Note, estimates of the uninsured population vary somewhat in different surveys. One factor is the time period specified --e.g., uninsured currently vs. ever uninsured in the last year.)

Given the current, employer-based system, lack of insurance soars among unemployed Americans (excluding retirees). And there the public favors changes as well. Eighty-two percent support expanding state-run health programs for low-income people, such as Medicaid and the Children's Health Insurance Program. Alternatively, about as many support tax credits or other aid to help the poor buy private health insurance.

In another approach, three-quarters like the idea of expanding Medicare, the government program that covers retirees, to cover people as young as age 55 who lack other health insurance; 55 percent strongly back this proposal. (Support is lower among seniors, who may fear that expanding the popular program could endanger it.)

Another notion -- requiring all Americans to obtain health insurance, with tax credits to help the poor pay for it -- gets two-thirds support. But strong support for this, the most sweeping of these proposals, is lowest -- just 35 percent. Again it seems the most-preferred approaches are not the most systemic ones.

This poll measures baseline support for all these measures; each would likely be heavily debated, and various lines of criticism (for example, negative assessments of their impact on jobs or taxes) could potentially impact their popularity.

In one example of movable attitudes, while 65 percent in general favor requiring all Americans to have health insurance, there's less support specifically for a mandatory plan like the one in Massachusetts, which carries penalties for being uninsured. That plan gets 52 percent support; the drop occurs overwhelmingly among conservatives, possibly given Massachusetts' reputation as a liberal state.

Consumer-Directed Plans -- In another direction, nearly eight in 10 Americans think that allowing people to shop around for their own medical care would be an effective way to control costs. But the idea of consumer-driven care looks less popular if it's accompanied by the risk of higher out-of-pocket expenses.

Making consumers more aware of the cost of care is a motivating force behind proposals such as "health savings accounts." In these people would be insured only for major medical needs; for routine care they'd have an annual pool of money to spend as they chose, but once depleted, further routine care would come from their own pocket. This poll finds that two-thirds oppose the idea, including as many conservatives as liberals, and six in 10 Republicans along with 73 percent of Democrats.

Such proposals are complex; other aspects could enhance their appeal in some groups, such as tax breaks on contributions made by employers and individuals; lower premiums; and the accumulation of unspent health care funds in the accounts, which can be rolled over from year to year and job to job. Still, the risk associated with these arrangements appears to be a significant hurdle for consumer-driven health plans to overcome.

Cost -- The overall cost of health care in this country is a very broad concern. Eighty percent of Americans are dissatisfied with the level of total health care spending; 58 percent are "very dissatisfied." And while 57 percent are satisfied with their own current costs, that's far lower than the level of personal satisfaction with other aspects of health care, such as coverage and quality.

Additionally, two-thirds of those who are insured say their costs for health insurance premiums have been rising lately. (These results are about the same now as in a 2003 ABC News/Washington Post poll that asked many of these same questions.)

One likely reason discontent with personal costs isn't higher is because employers, rather than their insured workers, bear most of those costs. Just three in 10 insured Americans say their premiums have been rising "a lot." Fewer than half, 48 percent, say their deductibles and co-pays have been rising at all, and just 19 percent say these have been rising a lot.

Nonetheless, as noted, 60 percent are worried about their future costs for health insurance. And people who are worried are much more likely than others to support the most fundamental change, a shift to a universal coverage system.

The Uninsured -- The uninsured, who lack employer-provided insulation from rising health costs, are far more vulnerable. Thirteen percent of Americans in this survey say they currently lack health insurance, and an additional seven percent say they've gone without insurance at some point in the last year. (In recently released data from the U.S. Census Bureau, 17.4 percent of adults lacked coverage in all of 2005.)

It's clearly a public health concern: Uninsured people are far more likely to have had problems paying medical bills in the past year, and to have put off treatments because of costs. And even though they're younger (in general a healthier group), people who lack health insurance are much more likely than others to say their own health is bad --28 percent vs. 10 percent.

Income is a key factor in being insured. Among people with household incomes of $50,000 a year or more, just three percent report being currently uninsured, compared with nearly one in four among those with household incomes under $50,000. And among just the lowest-income Americans, those earning less than $20,000, more than one in three say they currently lack coverage.

There are vast differences in the type of coverage for those who are insured. Among better-off Americans, 87 percent report having private health insurance. Among those with less than $50,000 in household income, this falls to 48 percent. And in less than $20,000 households it bottoms out at just two in 10.

Lack of insurance also peaks among younger adults, 22 percent of those under age 30.

Uninsured Americans are far more likely than insureds to express dissatisfaction with the U.S. health care system and their personal situation alike. The largest gap, naturally, is in ratings of their own health care costs: Eight in 10 of the uninsured are dissatisfied, compared with a third of insured people.

More uninsureds also are more worried about the future, and more deeply so. Six in 10 insured people are worried about affording their health insurance over the next few years, including about a quarter who are very worried. But 85 percent of the uninsured are worried about being able to afford health care, with more than six in 10 very worried.

Given their dissatisfaction and future concern, uninsured Americans overwhelmingly prefer a universal health care system to the current one, and are more likely than insured people to think it would improve the quality, costs and availability of their own care.

Asked why they're uninsured, most people say it's because they can't afford coverage. Among the rest, about one in seven say they've been refused insurance because of ill health or similar reasons; as many say it's because their employer doesn't offer it or they're not eligible under their employers' plan.

Problems Paying -- As noted, 25 percent of Americans say they or another family member in their household have had problems paying medical bills in the past year. That's ranged from 18 to 23 percent in five previous polls by Kaiser dating to 1997.

There's also been a change in the severity of these problems: Among those who report problems paying, the number who say such bills have had a "major impact" on their family has risen from 48 percent in 2000 to 55 percent in 2003 and 61 percent now.

Similarly, 28 percent of Americans now say that within the past year they or a family member have put off medical treatment because of the cost; that's ranged previously from 14 to 25 percent in polls since 1991. Among those who've put off treatment, 70 percent say it was for a serious condition or illness – about the same as in 2003, but up from a low of 52 percent in a 1991 Gallup poll.

WOMEN and CARE --In a striking result, women are nearly twice as apt as men to say they or someone in their family have put off treatment because of the cost -- 36 percent of women say they've done so, compared with 19 percent of men.

That peaks particularly among women with children, among whom 46 percent – nearly half -- say they or someone in their family have put off care. And these women are no less apt than anyone else to say the postponed care was for a serious illness or condition.

A 2002 poll by the Kaiser foundation also found a gap, but a smaller one, between men and women in postponing medical care because of costs. (Women, it's worth noting, tend to be heavier users of the health care system, increasing their opportunity to put off care.) That 2002 poll specified personal care, while this survey asks about postponed care for anyone in the family.

Women also are likelier than men to report problems paying medical bills in the past year, albeit by somewhat less of a margin – 30 percent of women, 20 percent of men. Again, problems paying medical bills peaks in particular among women with children.

Among other groups, people in bad health are much more likely than those in good health to have put off needed medical care, and to report problems paying medical bills. Problems paying medical bills also are higher in groups including younger and lower-income Americans, racial minorities and the unemployed.

Causes -- As far as the cause of higher health costs, the public's biggest suspicion is profiteering by drug and insurance companies -- 50 percent call this one of the single biggest factors. Fraud and waste, the cost of medical malpractice suits and doctors and hospitals making too much money also come in for substantial concern.

About three in 10 also cite administrative costs, unnecessary treatments, unhealthy lifestyles and expensive new drugs and technology. Last on the list is the notion that more people are getting better care than ever: Just 12 percent see this as a top factor in rising health care costs.

Pressure on costs looks unlikely to drop, given the interest in high-end treatments and technology. Forty-seven percent of Americans think expensive new drugs, treatments and technology produce better results than older, less expensive alternatives. (There's less support for the idea that high-end doctors make much difference: Just 21 percent think more expensive doctors provide better medical care.)

While there's plenty of interest in medical products and procedures, there's still hope for cost control: Most people want these to be proven before insurance covers them. Seventy-two percent say insurance should cover expensive new drugs or treatments only if they've been shown to be more effective than other, less expensive options. Sixty-two percent feel that way even if a doctor recommends the higher-end alternative.

End of Life and Higher Risk -- Even though the aging population is not seen as a leading factor in rising costs, the high cost of end-of-life care does come in for scrutiny. Forty percent of Americans say a terminally ill person should be kept alive as long as possible, regardless of the cost. Forty-eight percent, instead, say it's better to make a judgment as to whether it's worth the expense to keep that person alive.

Interestingly, senior citizens are more likely than others to say it's better to make a cost/benefit judgment. Sixty percent say so, compared with 47 percent of adults 18-64.

In another area, there's broad support for charging higher health insurance premiums for people who smoke cigarettes – 63 percent favor the idea. But far fewer (30 percent) favor higher premiums for people who're overweight. Self-interest may be at play -- about a quarter of Americans smoke, while two-thirds are overweight.

Quality --As noted, very sizable majorities of Americans rate the quality of their current care positively, and these ratings too are essentially unchanged since 2003. Nonetheless they're far from perfect: While most are satisfied with their own care, coverage and even cost, far fewer are "very" satisfied.

For instance, while 88 percent say their coverage overall is excellent or good, that includes just 33 percent who call it "excellent." While 57 percent are satisfied with their own costs, just 23 percent are very satisfied. And even on overall quality of care, while 89 percent are satisfied, fewer are very satisfied, 52 percent.

While these are little changed from 2003, several have been much better. Most notably, in 1995 and 1997 polls about three-quarters were satisfied with their health care costs, compared with today's 57 percent. And the number who are "very satisfied" with their ability to get the latest treatments, see top specialists and get a doctor's appointment, are, respectively, 17, 15 and 11 points lower now than in 1995.

Most people with coverage, 80 percent, also say their plan tends to pay their medical expenses without much problem. However, a substantial number, 32 percent, say their plan has at some point refused to pay for all or part of a treatment that they thought should have been fully covered. That concern peaks, at 38 percent, among people who say they're in PPOs, preferred provider organizations, which have grown to be the most popular form of private health insurance. Among Americans with private insurance, 45 percent now report being in PPOs, up from 29 percent in 1995.

Serious Illness -- Some might speculate that it's easy to be satisfied as long as you haven't had serious medical problems. Instead, satisfaction runs as high -- and top-level satisfaction even higher -- among people who've experienced a serious illness or injury or a chronic, ongoing illness under their current health plan.

Among such people, 90 percent say they're satisfied with the quality of care they received during that time, and 60 percent are very satisfied with that care. Similarly, 87 percent in these cases are satisfied with their health insurance coverage during that time, and again more, 56 percent, are very satisfied with the coverage they received.

High-level satisfaction with care and coverage alike in these cases peaks among people who report having traditional health insurance coverage, with no restrictions on which doctors they can see; it's lowest among people who say they're in HMOs. In traditional plans, 71 percent are very satisfied with the care they received; in HMOs, it's 49 percent. (Self-reported participation in traditional plans has declined from 43 percent of privately insured Americans in 1995 to 24 percent now. Employers surveyed by Kaiser and the Health Research and Educational Trust report fewer people in traditional plans than this poll finds, and more in PPOs; how people use or perceive their plans may be a factor.)

HMOs --There are other notable differences between people who say they're in HMOs and those who say they're in other types of plans. Generally, overall satisfaction with HMOs is as high, but top-level satisfaction is substantially lower.

People in HMOs are as likely as other insured Americans to rate their coverage positively overall (87 percent do so), as well as their quality of care (93 percent). But just 25 percent in HMOs rate their coverage as excellent, compared with a high of 40 percent of people in traditional plans; and 47 percent in HMOs rate their quality of care as excellent, compared with about six in 10 in traditional plans, PPOs and Medicare alike.

Similarly, 48 percent in HMOs are very satisfied with the quality of their communication with their doctors, compared with 70 percent in traditional plans; 47 percent in HMOs are very satisfied with their ability to get a doctor's appointment when they want one, compared with 65 percent in traditional plans; 38 percent in HMOs are very satisfied with their ability to see top specialists, compared with 63 percent in traditional plans; and 35 percent in HMOs are very satisfied with their ability to get the most sophisticated treatments, compared with 51 percent in traditional plans.

Priorities --While self-interest is a factor in views on health care policies, it's not the sole motivator. Indeed 68 percent in this survey say it's more important to provide health care coverage for all Americans, even if that means raising taxes, than to hold down taxes, if that means some Americans lack coverage. (This is, however, down from 79 percent in 2003.)

This view has a partisan cast: Eighty-four percent of Democrats say it's more important to cover all Americans than to keep taxes down, as do 66 percent of independents. Fewer Republicans – but still about half, 49 percent – agree. The divisions among liberals, moderates and conservatives are similar (86, 72 and 52 percent, respectively).

There's more division on another policy matter, whether it's more important to reduce health care costs (50 percent say so) or to increase the number of insured Americans (42 percent). Uninsured people are more likely to say it's more important to cut health care costs than to increase coverage; costs apparently are their most pressing concern. Similarly, lower-income Americans also say it's more important to cut health care costs than increase coverage. Even people who prefer a universal system over the current one are split over what's more important.

Six in 10 Republicans say lowering costs is more important; Democrats and independents are more divided.

Universal --While 56 percent support a shift to universal coverage, far fewer, ranging from 15 to 26 percent, think such coverage would actually improve the quality or cost of their own care, the availability of treatments, or their choice of doctors or hospitals. Indeed by 2-1 people think universal coverage would make the quality of their own care worse, and by better than 2-1 think it would worsen their choice of doctors or hospitals.

Support for universal health care peaks among those who'd benefit the most from it -- the uninsured. Eight in 10 support universal care, compared with just over half of insured people. Support is also much higher among those who call the uninsured population a critical problem, than among those who don't, 69 percent to 43 percent.

Support for universal coverage likewise is higher among people who've had problems paying their medical bills and have put off treatment because of the cost, and among lower-income adults. It's higher among people who are dissatisfied with current costs and quality of care. And universal care does better among people who're worried about future costs, or losing their current coverage.

Naturally, a universal coverage system gets broad support from people who think it would improve the quality, cost and availability of their health care, but it's also favored by most people who think these would stay the same under such a system. Indeed, in a show of altruism, universal coverage is supported by a quarter of those who think the quality of their care and the availability of treatments would worsen, and by just over three in 10 of those who think their costs would rise and their choice of doctors would suffer under such a system.

Partisanship also comes into play. More than seven in 10 Democrats and nearly two-thirds of independents favor universal coverage, compared with just three in 10 Republicans. Similarly, three in four liberals and six in 10 moderates prefer it to the current system; four in 10 conservatives agree.

While Democrats and independents express the same level of support for a universal system that they did in 2003, Republicans are now 14 points less likely to favor it.

Among age groups, support for a universal system peaks among those under age 30, and is lowest among seniors.

Politics -- Partisanship affects support for various health care solutions. Overall, Democrats are more likely than Republicans to support almost all the proposals tested in this poll. And their preferred approaches are different. Tops for Democrats are employer mandates for full-time workers and expanding state programs for the poor. Republicans are most in favor of offering tax breaks to businesses that provide insurance, and offering tax credits or other aid to help low-income people buy private insurance.

Overall, this poll finds the Democratic Party with a 17-point lead over the Republicans in trust to handle health care issues. And while it ranks below Iraq and the economy as a top-level election concern, the issue does have political potency. Nearly three in 10 Americans rate it as one of the top two issues in their vote for Congress this year, with women twice as apt as men to call it the single most important issue in their vote.

Methodology -- This ABC News/Kaiser Family Foundation/USA Today poll was conducted by telephone Sept. 7-12, 2006, among a random national sample of 1,201 adults. The results have a three-point error margin. Sampling, data collection and tabulation by TNS of Horsham, Pa.